EDITORIAL

Addressing indigenous1 substance misuse and related harms

DENNIS GRAY1, LISA JACKSON PULVER2, SHERRY SAGGERS3, & JOHN WALDON4

1National Drug Research Institute, Curtin University of Technology, 2Muru Marri Indigenous Health Unit, School of Public

Health and Community Medicine, Faculty of Medicine, University of New South Wales, 3Centre for Social Research, Edith

Cowan University, and 4Research Centre for M�aori Health and Development, Massey University

Introduction

Substance misuse and its consequences among indi-

genous minority populations in countries such as

Australia, New Zealand/Aotearoa, Canada and the

United States is a major health and social problem. In

Australia among Indigenous peoples, the proportion of

tobacco smokers is twice that in the non-Indigenous

population; there is a higher proportion of people who

consume alcohol at harmful and hazardous levels; there

are higher rates of illicit drug use, including injection of

illicit drugs; and there are higher rates of volatile

substance misuse, including petrol fume inhalation.

These higher rates of substance misuse are accompa-

nied by commensurately higher rates of alcohol- and

other drug-related morbidity and mortality and rates of

violence and other forms of social disruption [1].

Although there is some variation in the specific rates

of use and their consequences, the patterns of

substance misuse among indigenous minority peoples

in New Zealand/Aotearoa, Canada and the United

States are broadly similar to those found in Australia

[1 – 4]. That these peoples are ethnically and culturally

diverse highlights the role of their common histories of

dispossession and continuing economic and social

marginalisation in the ætiology of substance misuse

and related problems.

Although the overall pattern of substance misuse and

its consequences have been documented, there remains

a significant gap in our knowledge. For example, in

Australia, studies of consumption are either dated, too

small in scale to be generalised, and/or are of poor

quality (cf. the paper by Chikritzhs & Brady in the Harm

Reduction Digest of this issue of the Journal). Never-

theless, many indigenous people, and others in the field,

are impatient with calls for more studies which docu-

ment the extent of problematic substance misuse. To all

of us, the magnitude of the problem is obvious: we want

action to address it and, importantly, the Indigenous

communities are the ones to direct that action.

Such action needs to take place on two fronts.

Generally, it needs to address the underlying structural

determinants of Indigenous health (including substance

misuse) – including lack of meaningful employment, an

educational system that has largely failed Indigenous

Australians, poverty and lack of opportunity to accu-

mulate life-long assets, social and financial capital [5].

Specifically, it needs to be directly targeted at reducing

harmful consumption patterns and levels, and pro-

viding substance misuse intervention programmes.

Clearly, in Australia, some action has been taken on

these fronts—with three decades of intervention,

including Indigenous employment, education and

housing and infrastructure programmes and various

substance misuse programmes (including the relatively

recent development of the National Drug Strategy

Aboriginal and Torres Strait Islander Peoples Comple-

mentary Action Plan [6]). Just as clearly, however—as

attested by various statistical profiles [7]—these actions

have been insufficient to shift the balance of Indigenous

inequality.

Dennis Gray MPH, PhD, Associate Professor and Deputy Director, National Drug Research Institute, Curtin University of Technology, Perth,Western Australia, Lisa Jackson Pulver PhD, Muru Marri Indigenous Health Unit, School of Public Health and Community Medicine, Faculty ofMedicine, University of New South Wales, Sydney, New South Wales, Sherry Saggers PhD, Professor and Director, Centre for Social Research,Edith Cowan University, Perth Western Australia, John Waldon BSc, MPH, Research Officer/HRC Training Fellow in Maori Health, ResearchCentre for M�aori Health and Development, Massey University, Palmerston North, New Zealand. Correspondence to Associate Professor DennisGray, National Drug Research Institute, Curtin University of Technology, GPO Box U1987, Perth, Western Australia, 6845.E-mail: d.gray@curtin.edu.au1In this and the other papers in this section, we use ‘indigenous’ uncapitalised as a common noun to refer to indigenous peoples in general, and‘Indigenous’ capitalised as a proper noun to refer to particular Indigenous peoples such as Indigenous Australians.

Received 13 January 2006; accepted for publication 20 January 2006.

Drug and Alcohol Review (May 2006), 25, 183 – 188

ISSN 0959-5236 print/ISSN 1465-3362 online/06/030183–06 ª Australasian Professional Society on Alcohol and Other Drugs

DOI: 10.1080/09595230600644616

Indigenous communities are diverse in terms of

culture, history and geographic location. They also have

a long history of struggle to control and affirm their own

affairs—an approach that is well justified given the

failure of many top-down, mainstream interventions

and the evidence that self-governance has resulted in

more positive outcomes for indigenous peoples in other

settler societies [8]. Until recently, governments have

sought to accommodate Indigenous control—to vary-

ing degrees—through policies of ‘self-determination’

and ‘self-management’. Under such policies—

particularly those at the federal level—governments have

provided funding directly to Indigenous community-

controlled organisations to implement intervention

projects initiated by those organisations.

There has been only one comprehensive attempt to

document the full range of substance misuse specific

intervention projects in Australia (or elsewhere) [9].

This was conducted for the 1999 – 2000 financial

year. At that time there was a total of 277 projects

being conducted which targeted substance misuse

directly among Indigenous Australians. The projects

were conducted by 213 organisations, of which 177

were Indigenous community-controlled organisations;

20 were government agencies; and 16 were non-

Indigenous non-government organisations. The pro-

jects conducted by Indigenous organisations included

38 that were conducted by community-controlled

health services. (In addition to those conducting

substance misuse specific projects, all community-

controlled health services provided general health care

and other interventions for people with substance

misuse problems.) This mapping exercise also demon-

strated the lack of fit between funding and evidence-

based interventions for substance misuse. Importantly,

few such Indigenous-specific substance misuse inter-

vention projects have been comprehensively evaluated

and those evaluations that have been conducted are

variable in quality [10,11].

It is against this background that this special section

on Indigenous issues is presented.

The papers

We were approached by the Editorial Board of Drug

and Alcohol Review to edit this Special Section of

Indigenous Substance Misuse Issues. To ensure the-

matic consistency and to avoid having many people

working on papers that might not be published, instead

of calling for full papers we solicited expressions of

interest in preparing papers for inclusion. In total, we

received 20 such expressions. These were ranked

independently by three of the editors with preference

given to papers authored or co-authored by indigenous

people. On the basis of these rankings, we commis-

sioned papers from 10 groups. Subsequently, two of

those groups withdrew. First drafts of the papers were

reviewed independently by three of the editors and final

versions of the papers received between late November

2005 and early January 2006.

The work described in the papers has been con-

ducted in a range of settings—remote (Preuss & Brown,

Ivers et al., Brady et al.), regional town (Hogan et al.,

Foster et al.) and urban (van der Sterren et al., Williams

et al.). They cover a range of substances—petrol

(Preuss & Brown), tobacco (Ivers et al.), alcohol (Brady

et al., Hogan et al., Foster et al.) and illicit drugs

(van der Sterren et al., Williams et al.). Australia’s

National Drug Strategy is based on the principle of

harm minimisation, which encompasses the particular

strategies of demand reduction, supply reduction and

harm reduction [12], and each of the papers in this

Section considers some particular aspect of these—

harm reduction (Brady et al.), demand reduction (Ivers

et al., Preuss & Brown, Williams et al.), supply reduc-

tion (Hogan et al.) as well as the broad issues of harm

minimisation (van der Sterren et al) and work-force

development (Robertson et al.).

Seven of the eight papers presented are authored or

co-authored by Indigenous people. These Indigenous

people are ‘researchers’ practicing in the broadest

sense. They include some individuals who are em-

ployed in academic institutions, and others who are

health service administrators and service providers.

What they have in common is a role in working actively

to improve the health and welfare of indigenous

people—whether at the local, regional or national

level—and in this capacity, to varying extents, have

played crucial roles in the development and conduct of

the interventions. From an academic perspective, many

do not have formal research qualifications; but they are

highly skilled in the task of doing research in their own

communities. They bring to the conduct of research an

intimate knowledge of the kind of methods that are

appropriate, and are able to understand and translate

this data into something meaningful in both community

and research contexts. In short, they bring new tools to

the research process and often validate the analysis of

the data collected in a manner that makes the transfer

of knowledge and action to the participant communities

a natural outcome of the research—providing an

additional validation step often not available to ‘main-

stream’ researchers.

With the exception of the review article by Robertson

et al., the papers are largely descriptive. There are

several reasons for this. There are various methodolo-

gical difficulties in applying standard research designs

to many projects conducted in indigenous commu-

nities, not least of which are objections by indigenous

peoples that such research is neither appropriate nor

ethical [13 – 15]. This has meant that much indigenous

substance misuse research has focused on small one-off

184 Editorial

interventions, for which it is often difficult to obtain

evaluation funding. This is epidemiology at the edge of

the lamp-light, beyond the shadow of Snow’s pump

handle. Furthermore, the number of researchers work-

ing in the area is small and the work is undertaken in

partnership by practitioners and researchers. Successful

research in this area is reliant upon the establishment of

long-term relationships of trust and reciprocity between

researchers and indigenous communities, and commit-

ments to build indigenous research capacity [16]. For

researchers, this means much longer time frames to

build research relationships, conduct research and

publish the results.

As those who followed media reports on an inquest

into the deaths of young men in the Northern Territory

in August 2005 [17] will know, petrol sniffing is an issue

of major concern in many remote communities, and a

review by MacLean & d’Abbs has highlighted the

paucity of reports evaluating petrol sniffing inter-

ventions [18]. This is the topic of the first paper, by

Preuss & Brown, which describes the broad-based Mt

Theo programme to tackle petrol sniffing through the

removal of sniffers to an outstation where petrol is not

available and the provision of preventative activities for

young people, including sport and cultural pursuits.

Although the programme has been cited widely in the

popular media as a successful approach to petrol

sniffing, the paper by Preuss & Brown is the first

detailed outline of the programme’s history and

approach. The paper highlights several elements in

the programme’s success, including its multi-faceted

approach, community involvement and strong partner-

ships between Indigenous and non-Indigenous staff

members.

Despite the emphasis on alcohol and illicit drugs by

government and Indigenous people, tobacco smoking

remains one of the greatest threats to the health of

Indigenous Australians. Indigenous people are twice as

likely to smoke as the general population in Australia

and, like other socio-economically marginalised popu-

lations, they are less likely to heed promotional

campaigns to quit. The paper by Ivers and her

colleagues focuses on a project to assess the potential

of community stores to implement health promotion

programmes aimed at reducing supply of, demand

for, and harm from tobacco. The controls that could

be exercised were in part subverted by vending

machines accessible to the whole community and

independent vendors who were not held accountable

to advertising and sales regulations. The stores pro-

vide potential health promotion site which, along with

aiding in the reduction of tobacco consumption, could

also improve the access to subsidised food. The

risk would be alienation from communities if there

was a perception that this was being imposed on them

unilaterally.

Reduction of alcohol-related harm in a remote

community is the focus of the paper by Brady and her

colleagues. Although they are a popular form of

intervention [9], there are have been few evaluations

of sobering-up shelters. Brady et al. provide a compre-

hensive description of the operation of, and admissions

to, a shelter in Ceduna in South Australia. Like

shelters, elsewhere, it removes intoxicated people to a

supervised location where they can be prevented from

harming themselves or others.

The paper by Hogan and her colleagues focuses upon

an attempt to reduce alcohol-related harm in Alice

Springs by means of a number of additional restrictions

on licensed liquor outlets. One of the most important of

these was a ban on the sale of beverages in containers of

more than 2 litres—an indirect price control measure as

it took the cheapest beverage, cask wine, off the market.

However, this latter restriction was circumvented when

some licensees began promoting the sale of 2-litre

containers of port for essentially the same price per

standard drink as wine in larger casks had been. There

was considerable support for addressing the ‘port

issue’—as reflected in both the official report on the

evaluation of the restrictions [19] and in the survey of

Town Camp residents reported on by Foster and her

colleagues. However, the Licensing Commission did

not choose to intervene and, at the end of the trial

period, the ban on containers of more than 2 litres was

reinstated. As the Alice Springs paper demonstrates,

while restrictions were largely successful local restric-

tions can be circumvented by licensees, despite the

views of the wider community. This has led Central

Australian Aboriginal Congress—the organisation by

which Hogan et al. are employed—to call for the trial of

an alternative price control measure which, on the face

of it, neither contravenes National Competition Policy

nor the provisions of the Australian Constitution which

preclude states and territories from influencing price

through the levy of excise duties.

The paper by Foster and her colleagues also deals

with the Alice Springs restrictions. However, it focuses

on a unique collaboration between an Indigenous

organisation and university-based researchers which

resulted in a culturally appropriate approach to

investigating the attitudes of Indigenous Town Camp

residents to the restrictions. This project demonstrates

that Indigenous people with limited literacy in English

can contribute to valid research about sensitive issues in

their communities.

Despite forming the basis of Australia’s National

Drug Strategy, the principle of harm minimisation is

contested by some segments of the broader commu-

nity, particularly in the context of illicit drug use.

Such contestation is particularly marked in Indige-

nous communities and this is highlighted in the

papers by van der Sterren et al. and Williams et al.

Editorial 185

As van der Sterren and her colleagues point out,

tensions are exacerbated by the limited range of

culturally safe services, in which illicit drug users come

into close contact with other members of the Indigenous

community in Melbourne. They propose a model of

harm minimisation that explicitly confronts these

tensions and which addresses community needs at the

local level—including the development of partnerships

between Indigenous and non-Indigenous service

providers.

The paper by Williams et al. complements that of

van der Sterren and her colleagues and provides a

practical example of such an approach. The Parks

Community Health Service, a South Australian Govern-

ment agency—in co-operation with Nunkuwarrin Yunti

Aboriginal Health Service and Drug and Alcohol

Services South Australia—is providing a successful

opioid substitution treatment service. This is based on

harm minimisation principles in an Indigenous com-

munity polarised in its views between abstinence and

harm minimisation approaches to illicit drug use (with

a majority favouring an abstinence approach), and

outcome measures include the experiences of commu-

nity members affected by the actions of opioid users.

The paper by Robertson et al. identifies five crucial

elements of work-force development for improving the

delivery of substance misuse programmes for M�aori:

(1) increasing capacity, recruitment and retention;

(2) increasing capability, training and development;

(3) providing supportive working environments, orga-

nisational/service development; (4) evidence-based

practice, research and evaluation, and; (5) work-force

development infrastructure. The paper has particular

relevance for Australia, where reviews of evaluated

substance misuse projects in Australia have frequently

identified a shortage of trained staff as an impediment to

the effective intervention [10,11] and where, in the

1999 – 2000 financial year, less than 2% of the $35

million allocated directly to Indigenous substance

misuse projects was for work-force development [9].

Since that time, in Australia, considerable effort has

been put into the second of the elements identified by

Robertson and his colleagues – with the development of

particular resources by organisations such as the

Alcohol and Drug Council of South Australia [20,21]

and, under the auspices of the Ministerial Council on

Drug Strategy, the current development of a nationally

accredited training programme for Indigenous commu-

nity drug and alcohol workers. However, there remains

considerable scope to address the other four elements.

An important point raised by Robertson and his

colleagues (also raised by Williams et al.) is that:

Training non-indigenous clinicians to work more

effectively with indigenous peoples is crucial to

developing more responsive services given that a

large number of indigenous clients access non-

indigenous clinicians . . .

This is true also in Australia, particularly in primary

health and medical care settings, where have been calls

for greater attention to the training of non-Indigenous

workers [22].

Lessons

The papers in this Special Section illustrate some

important lessons for the drug and alcohol field about

interventions and conducting research on substance

misuse with indigenous communities. The issues

include: questions about appropriate methodologies

for indigenous research; the role of indigenous people

in interventions and the conduct of research; the rela-

tive paucity of evaluated interventions; the applicability

of policies and interventions within and between

indigenous and non-indigenous communities; the

importance of partnerships between indigenous and

non-indigenous people, both for successful interven-

tions and valid research; and the need for interventions

which address all levels in the hierarchy of the structural

determinants of substance misuse.

Appropriate research methodologies

Some of the papers are written by people who are

publishing for the first time, and the projects they

describe are unlikely to have appeared in any other

scholarly publication. In part, this is because the

projects they describe are one-off interventions among

small populations, based on qualitative research designs

agreed upon after extensive negotiation between

researchers and indigenous communities. A consider-

able amount has been written about the need for

research on indigenous issues to be conducted by

indigenous people, using indigenous methodologies

[14,23 – 25]. This means that non-indigenous people

wanting to research indigenous issues need to learn new

ways of doing research that honour indigenous people’s

views. Such approaches will also contribute to a more

robust evidence base for interventions.

The role of Indigenous people

One of the key elements identified as integral to both

interventions and research is the need for Indigenous

people to be involved at all stages. With intervention

initiatives, this means from policy and programme

development, through intervention, to evaluation. This

includes interventions that are conducted by gov-

ernment agencies—as illustrated in the papers by

Williams et al. and Ivers et al. In terms of research, it

means indigenous people initiating discussions about

186 Editorial

appropriate research, and full involvement with grant

applications/proposals, data collection and analysis and

writing and dissemination of research results. All but

one of the papers in this Section are authored or co-

authored by indigenous people and they make an

important contribution to the establishment and devel-

opment of an indigenous literature on alcohol and other

drug issues.

Paucity of evaluated interventions

As noted earlier, evaluated indigenous-specific substance

misuse interventions are few and variable in quality

[10,11]. There are many reasons for this, including lack

of resources; shortage of trained personnel (especially

within community-controlled organisations); the diffi-

culty of using standard epidemiological approaches

because of the scale of projects; lack of agreement

(between organisations and funding agencies) about the

objectives of projects and appropriate indicators of

‘success’; and resentment of non-Indigenous researchers

who are often perceived as (often inadvertently) further-

ing their own careers but providing little practical benefit

to indigenous communities [13 – 15,24]. We hope these

papers provide a foundation for discussions around

appropriate evaluation methodologies for indigenous

substance misuse interventions.

Applicability of policies and interventions

Mainstream drug and alcohol policies cannot be

applied uncritically to indigenous populations. As

illustrated with regard to ‘harm minimisation’ in the

papers by van der Sterren et al. and Williams et al.—

because of their diversity—the application of the policy

needs to be negotiated and implemented with due

consideration for the diverse histories, cultures and

social settings of the communities in which it is applied.

For the same reasons, as Preuss & Brown discuss,

interventions developed in one community cannot

simply be applied in another community. However,

there are key elements that have contributed to

successful interventions in different settings, and these

can be applied elsewhere.

Partnerships between indigenous and

non-indigenous people

One of the key elements of success in both interven-

tions and research have been collaborative partnerships

between indigenous and non-indigenous people. Part-

nerships between indigenous and non-indigenous

people and organisations are also essential for success-

ful intervention. This is illustrated in the papers by

Hogan and her colleagues and Preuss & Brown. In the

case of Alice Springs, where Indigenous people are a

minority within the population, Indigenous organisa-

tions formed coalitions with non-Indigenous groups to

successfully lobby for liquor licensing restrictions.

These partnerships have been successful because they

are built upon long-term relationships which have

allowed trust to develop, and the time to determine

how the knowledge and skills of each partner can enrich

the work undertaken.

Levels of interventions

While community level interventions are important,

they must be supported by interventions that address all

levels of the hierarchy of structural determinants, from

the macro-social to the individual. This is highlighted in

the papers by Hogan et al. and Robertson et al. The

paper by Hogan and her colleagues illustrates the point

that, while in some instances local restrictions can be

effective, they can also be circumvented and that what

might be required to reduce alcohol-related harm is

action on a broader level.

Conclusion

The papers in this Special Section do not provide ‘the

answers’ to substance misuse and related harms among

indigenous peoples. They do, however, raise some key

issues for further consideration among all those

concerned about the issues. In this regard, we believe

that the authors have made an important contribution

and are to be congratulated.

Acknowledgements

We would like to acknowledge all the people who have

participated in the work presented in this issue of the

Journal. The integral role of Aboriginal and Torres Strait

Islander people in research and projects such as these can

never be underestimated. Core funding for the National

Drug Research Institute is provided by the Australian

Government Department of Health and Ageing.

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